Diagnosis of Shock

Author: Jonathan M Jones / Editor: Steve Fordham / Reviewer: Stewart McMorrran, Nadarajah Prasanna, Rafeeq Ahmed Sulaiman / Code: / Published: 18/06/2021 / Reviewed: 13/03/2025

This session covers the assessment and management of shock in the emergency department (ED).

After completing this session you will be able to:

  • Describe what is meant by shock
  • Differentiate between the various causes of shock
  • Recognise the physical signs and symptoms of shock
  • Formulate a differential diagnosis for the shocked patient
  • Recall the tasks involved in the resuscitation and treatment of the causes of shock

START MODULE

References

  1. Hobson MJ, Chima RS. Pediatric Hypovolemic Shock. The Open Pediatric Medicine Journal, 2013, 7, (Suppl 1: M3) 10-15.
  2. Supporting information for mortality statistics, which present figures on deaths registered in England and Wales in a specific week, month, quarter or year. Office for National Statistics. Last revised: 10 October 2024.
  3. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000 Aug;30(8):1144-50.
  4. Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, Iwashyna TJ, Kadri SS, Angus DC, et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA. 2017 Oct 3;318(13):1241-1249.
  5. Jung RG, Stotts C, Gupta A, Prosperi-Porta G, Dhaliwal S, et al. Prognostic Factors Associated with Mortality in Cardiogenic Shock – A Systematic Review and Meta-Analysis. NEJM Evid. 2024 Nov;3(11):EVIDoa2300323.
  6. Moore FD. Shock and sepsis: some historical perspectives. Surg Clin North Am. 1969 Jun;49(3):481-7. doi: 10.1016/s0039-6109(16)38832-6.
  7. Rivers E, Otero R, Nguyen H. Approach to the patient in shock. In Emergency Medicine: A comprehensive study guide. Eds Tintinalli J, Kelen G, Stapczynski J 6th Ed New York 2004 McGraw Hill.
  8. Hinshaw LB, Cox BG. The fundamental mechanisms of shock, New York, 1972. Plenum Press.
  9. Levy MM. Pathophysiology of oxygen delivery in respiratory failure. Chest. 2005 Nov;128(5 Suppl 2):547S-553S.
  10. Guyton AC and Hall JE. Textbook of medical physiology. 13th Ed. London. Saunders 2015.
  11. Thomas I, Dixon J. Bradycardia in acute haemorrhage. BMJ. 2004 Feb 21;328(7437):451-3.
  12. Steiner MJ, DeWalt DA, Byerley JS.Is this child dehydrated? JAMA 2004;291:2746-2754.
  13. Lewin J, Maconochie I. Capillary refill time in adults. Emergency Medicine Journal 2008;25:325-326.
  14. Taylor MP, Wrenn P, O’Donnell AD. Presentation of neurogenic shock within the emergency department. Emergency Medicine Journal : EMJ. 2017 Mar;34(3):157-162.
  15. Working Group of the Resuscitation Council UK. Emergency treatment of anaphylaxis: Guidelines for healthcare providers. Resuscitation Council UK, 2021.
  16. Thompson MJ, Ninis N, Perera R at al. Clinical recognition of meningococcal disease in children and adolescents. Lancet 2006; 367:397-403.
  17. NCEPOD. An Acute Problem? May 2005.
  18. Fukui S, Higashio K, Murao S, et al. Optimal target blood pressure in critically ill adult patients with vasodilatory shock: a protocol for a systematic review and meta-analysis. BMJ Open 2021;11:e048512.
  19. Advanced Trauma Life Support. 10th Edition. American College of Surgeons Committee on Trauma. 2019.
  20. Marik PE. The optimal endpoint of resuscitation in trauma patients. Critical Care (London, England). 2003 Feb;7(1):19-20.
  21. Huang TY. Monitoring oxygen delivery in the critically ill. Chest 2005;128;554-560.
  22. Nguyen HB, Loomba M, Yang JJ, et al. Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock. J Inflamm (Lond). 2010 Jan 28;7:6.
  23. Dunne JR, Tracy JK, Scalea TM, Napolitano LM. Lactate and base deficit in trauma: Does alcohol or drug use impair their predictive accuracy? J Trauma 2005;58(5): 959-966.
  24. Pal JD, Victorino GP, Twomey P, Liu TH, Bullard MK, Harken AH. Admission serum lactate levels do not predict mortality in the acutely injured patient. J Trauma. 2006 Mar;60(3):583-7; discussion 587-9.
  25. Abramson D, Scalea T, Hitchcock, R et al. Lactate clearance and survival following injury. J Trauma 1993; 35(4):584-589.
  26. McNelis J, Marini CP, Jurkiewicz A et al. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg 2001;182(5): 481-485.
  27. Donnino NW, Miller J, Goyal N et al. Effective lactate clearance is associated with improved outcome in post cardiac arrest patients. Resuscitation 2007;75(2):229-34.
  28. Otero RM, Nguyen HB, Huang DT et al Early goal directed therapy in severe sepsis and septic shock revisited. Concepts, controversies and contemporary findings. Chest 2006;130:1579-1595.
  29. Adams BD, Bonzani TA, Hunter CJ. The anion gap does not accurately screen for lactic acidosis in emergency department patient. Emerg Med J 2006;23:179-182.
  30. Chetana Shanmukhappa S, Lokeshwaran S. Venous Oxygen Saturation. [Updated 2024 Sep 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  31. PRISM Investigators; Rowan KM, Angus DC, Bailey M, et al. Early, Goal-Directed Therapy for Septic Shock – A Patient-Level Meta-Analysis. N Engl J Med. 2017 Jun 8;376(23):2223-2234.
  32. Dellinger R, Levy M, Carlet J et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008;36(1):296-327.
  33. Bickell WH, Wall MJ, Pepe PE et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-9
  34. Gattinoni L, Brazzi L, Pelosi P et al. A trial of goal-oriented haemodynamic therapy in critically ill patients. N Engl J Med 1995;333:1025-32
  35. Kern JW, Shoemaker WC. Meta-analysis of haemodynamic optimization in high risk patients. Crit Care Med 2002;30(8):1686-92.
  36. Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane database of systematic reviews. 1997, Issue 4. Art.no: CD000567. DOI: 10.1002/14651858.CD000567.pub3. (Last substantive update July 2007).
  37. Hebert P, Tinmouth A, Corwin H. Controversies in RBC transfusion in the critically ill. Chest 2007;131:1583-1590.
  38. Task force for advanced bleeding care in trauma. Management of bleeding following major trauma: a European guideline. Crit Care 2007;11:R17.
  39. Singer M. Catecholamine treatment for shock equally good or bad? Lancet 2007;370:636-637.
  40. Pollard AJ, Nadel S, Ninis N, Faust S, Levin M. Emergency management of meningococcal disease: eight years on. Arch Dis Child 2007;92:283-286.
  41. Peacock WF and Weber JE in: Tintinalli JE, Kelen GD, Stapczynski JS Eds Emergency Medicine A Comprehensive Study Guide. New York, NY: McGraw Hill 2004 242-247.

Module Content

Expand All

Leave a Reply

BACK TO POST